______ Dollar Amount (starting at $ 25.00)

From: ______________________ To: __________________________

Total $ _________

Mail the gift certificate to:(check one)
RECEIVER PURCHASER

TO RECEIVER

FULL NAME _______________________________________

ADDRESS (if we send direct)___________________________

CITY, STATE, ZIP____________________________________

FROM PURCHASER

FULL NAME________________________________________

ADDRESS_________________________________________

CITY, STATE, ZIP____________________________________

Credit Card Information
circle one: Visa / Mastercard / Amex / Diner / Discover

Card Number _ _ _ _ | _ _ _ _ | _ _ _ _ | _ _ _ _ exp. __/__/____

Print Your Name as it appears on the card
______________________________________

Daytime Phone (____) ____-_____ Fax (____) ____-_____
Your Name(please print):______________________________________